Transfers, Ambulation Transfers, Ambulation Safety and RestraintsSafety and Restraints

Lesson Objectives (Transfers), By Lesson Objectives (Transfers), By the end of this lesson the student the end of this lesson the student vocational nurse will be able to:vocational nurse will be able to:

Describe the procedure for transferring Describe the procedure for transferring the client: moving up in bed, bed to chair, the client: moving up in bed, bed to chair, bed to stretcher, chair to bed,bed to stretcher, chair to bed,

Explain at least three safety factors Explain at least three safety factors practiced while performing a transferpracticed while performing a transfer

List common hazards encountered during List common hazards encountered during a transfera transfer

Explain the importance of knowing the Explain the importance of knowing the diagnoses and capabilities of the clientdiagnoses and capabilities of the client

Lesson Objectives (Ambulation), By Lesson Objectives (Ambulation), By the end of this lesson the student the end of this lesson the student vocational nurse will be able to:vocational nurse will be able to:

List common hazards of ambulation and List common hazards of ambulation and of using assistive devicesof using assistive devices

Explain the importance of knowing the Explain the importance of knowing the diagnoses and capabilities of the clientdiagnoses and capabilities of the client

Describe methods to support the client Describe methods to support the client during ambulationduring ambulation

Discuss various gaits used for walking Discuss various gaits used for walking with a cane, walker or crutcheswith a cane, walker or crutches

Create sample charting after ambulating a Create sample charting after ambulating a client, including the important dataclient, including the important data

Lesson Objectives (Restraints), By Lesson Objectives (Restraints), By the end of this lesson the student the end of this lesson the student vocational nurse will be able to:vocational nurse will be able to:

Discuss rationale for using restraintsDiscuss rationale for using restraints

Define the terms immobilize, legal rights, Define the terms immobilize, legal rights, limb holder, chemical restraintslimb holder, chemical restraints

Explain the patientExplain the patient’’s Bill of Rights regarding s Bill of Rights regarding consent of the client, family or guardian and consent of the client, family or guardian and written medical orders for use of restraintswritten medical orders for use of restraints

Discuss the procedure for applying various Discuss the procedure for applying various physical restraintsphysical restraints

Lesson Objectives (Safety), By the Lesson Objectives (Safety), By the end of this lesson the student end of this lesson the student

vocational nurse will be able to:vocational nurse will be able to:

Define vocabulary related to hospital/client environment.

Discuss purposes of space and how a nurse can respect the client's space.

Describe how to maintain the client's right to privacy.

Describe specific environmental factors that contribute to the comfort and safety of the client.

Discuss the effects of sensory deprivation for the client.

Identify personnel and committees that are involved in maintaining a safe, comfortable and the therapeutic environment in the hospital.

Discuss rationale for using restraints.

List the common types of injury that may occur in the hospital setting

Lesson Objectives (Safety), By the Lesson Objectives (Safety), By the end of this lesson the student end of this lesson the student vocational nurse will be able to:vocational nurse will be able to:

Define the terms:

a. Immobilized

b. Legal rights

c. Limb holder

d. Chemical restraints

Explain the Bill of Rights regarding consent of the client, family, or guardian and written medical orders for use of restraints.

Discuss the procedure for applying various physical restraints.

Transfers, Ambulation, Transfers, Ambulation, RestraintsRestraints

Safety !!!!Safety !!!!

Transfers, Ambulation, Transfers, Ambulation, RestraintsRestraints

(Safety Interventions):(Safety Interventions):

Assess for Orthostatic HypotensionAssess for Orthostatic Hypotension

DangleDangle

Client with special needs: (eg.) blind Client with special needs: (eg.) blind

Lock wheel chairs, stretchers and bedsLock wheel chairs, stretchers and beds

Check floors for safety (wet or clutter)Check floors for safety (wet or clutter)

Tub and shower surfacesTub and shower surfaces

Non-skid slippersNon-skid slippers

Common Hazards Common Hazards Encountered:Encountered:

Unable to assist or follow directionsUnable to assist or follow directions

Client fear Client fear

Client fatigueClient fatigue

Client weakClient weak

Problem with assistive devicesProblem with assistive devices

Inexperience of nurseInexperience of nurse

Size of client Size of client

Size of nurse Size of nurse

Supporting The Client:Supporting The Client:

PhysicallyPhysically

EmotionallyEmotionally

PsychologicallyPsychologically

Tips:Tips:

Moving from bed to chair:Moving from bed to chair:

Chair on strong sideChair on strong side

Pivoting (clientPivoting (client’’s hand on arm of chair)s hand on arm of chair)

Ambulating a Client:Ambulating a Client:

Support weak sideSupport weak side

Match clientMatch client’’s gates gate

Basic Nursing Care:Basic Nursing Care:

ComfortComfort

Safety Safety

Change PositionChange Position

Chair CushionsChair Cushions

ROM ExercisesROM Exercises

Orientation of ClientOrientation of Client

Therapeutic TouchTherapeutic Touch

Personal Items near Client Personal Items near Client

Client Daily HabitsClient Daily Habits

ADLADL’’SS

Documentation:Documentation:

TimeTime

DistanceDistance

Use of Assistive DevicesUse of Assistive Devices

ClientClient’’s Feelingss Feelings

WeaknessWeakness

Poor Balance Dizziness Poor Balance Dizziness

PosturePosture

Other ProblemsOther Problems

Number of People to AssistNumber of People to Assist

Procedure for Transfers:Procedure for Transfers:

Check the doctorCheck the doctor’’s orderss orders

Check diagnosis of the patientCheck diagnosis of the patient

Dangle (usually necessary-after BR)Dangle (usually necessary-after BR)

Assist client to a sitting position, legs at side Assist client to a sitting position, legs at side of bed, not touching the floorof bed, not touching the floor

Allow client to dangle for several minutesAllow client to dangle for several minutes

May be necessary to return client to bed May be necessary to return client to bed

Orthostatic Hypotension (Signs Orthostatic Hypotension (Signs and Symptoms):and Symptoms):

Dizziness Dizziness

WeaknessWeakness

FaintFaint

FatigueFatigue

Lightheadedness Lightheadedness

Orthostatic Blood Orthostatic Blood Pressures:Pressures:

LyingLying

SittingSitting

StandingStanding

Orthostatic Orthostatic Hypotension:Hypotension:

Systolic Blood Pressure Systolic Blood Pressure

drop < 25 mm Hgdrop < 25 mm Hg

Diastolic Blood PressureDiastolic Blood Pressure

drop < 10 mm Hgdrop < 10 mm Hg

Equipment (Transfers): Equipment (Transfers):

Wheel Chair with Replacement ArmWheel Chair with Replacement Arm

Geri ChairGeri Chair

Transfer BeltTransfer Belt

Sliding BoardSliding Board

Mechanical Lifts (Hoyer)Mechanical Lifts (Hoyer)

Bed ScaleBed Scale

Pull Sheet Pull Sheet

Moving Client Up In Moving Client Up In Bed:Bed:

Position on backPosition on back

Ask client to bend knees and push with feet Ask client to bend knees and push with feet on the count of threeon the count of three

Nurse assist client to the top of the bed Nurse assist client to the top of the bed (usually two person assist)(usually two person assist)

Use good body mechanics Use good body mechanics

Transfer (Two Person):Transfer (Two Person):

Very overweight clientVery overweight client

Confused clientConfused client

Uncooperative clientUncooperative client

Transfer To Chair from Bed:Transfer To Chair from Bed:

Dangle Position (may be first step)Dangle Position (may be first step)

StandStand

Pivoting (clientPivoting (client’’s arm on the arm of chair)s arm on the arm of chair)

Place chair on the clientPlace chair on the client’’s strong sides strong side

Ambulation (common hazards Ambulation (common hazards with assistive devices):with assistive devices):

BrokenBroken

Client not know how to useClient not know how to use

Pathways are not clearPathways are not clear

Equipment (ambulation)Equipment (ambulation)

Same with few exceptions Same with few exceptions

Gait BeltsGait Belts

CrutchCrutch

WalkerWalker

Ambulation: Prevent Ambulation: Prevent Falls !!!Falls !!!

Client Posture (head up, eyes open, looking Client Posture (head up, eyes open, looking forward)forward)

Non-skid slippersNon-skid slippers

Walk at clientWalk at client’’s sides side

Match clientMatch client’’s gates gate

Ambulation Ambulation (Procedure):(Procedure):

Walk on clientWalk on client’’s weak side/match gate s weak side/match gate

Stabilization (allow client to hold your elbow Stabilization (allow client to hold your elbow or hand)or hand)

Minimal Support (hold clientMinimal Support (hold client’’s arm with your s arm with your hand)hand)

Moderate Support (encircle clientModerate Support (encircle client’’s waist with s waist with your hand)your hand)

Maximum Support (two persons, one on each Maximum Support (two persons, one on each side of client)side of client)

SafetySafety

Define vocabulary related to hospital/client environment.

Air Pollution – the introduction of checmicals, the introduction of checmicals, particulate matter or biological materials that cause particulate matter or biological materials that cause harm or discomfort to human or other living harm or discomfort to human or other living

Carbon Monoxide - (CO), also called (CO), also called carbonous oxidecarbonous oxide, , is a colorless, odorless, and tasteless gas which is is a colorless, odorless, and tasteless gas which is slightly lighter than air. It is highly toxic to humans and slightly lighter than air. It is highly toxic to humans and animals in higher quantities, although it is also produced animals in higher quantities, although it is also produced in normal animal metabolism in low quantities, and is in normal animal metabolism in low quantities, and is thought to have some normal biological functions.thought to have some normal biological functions.

Carcinogen - s any substance, radionuclide or s any substance, radionuclide or radiation that is an agent directly involved in causing radiation that is an agent directly involved in causing cancer.cancer.

Vocabulary related to hospital/client environment:

Decibels - logarithmic unit that indicates the ratio logarithmic unit that indicates the ratio of a physical quantity relative to a specified or of a physical quantity relative to a specified or implied reference level ( noise ratio).implied reference level ( noise ratio).

Relative humidity - is a term used to describe the is a term used to describe the amount of water vapor in a mixture of air and amount of water vapor in a mixture of air and water vaporwater vapor

Sensory overload

Parasites - Parasites are organisms that obtain Parasites are organisms that obtain food and shelter by living on or within another food and shelter by living on or within another organism.organism.

Pathogens – microorganism that cause disease.Pathogens – microorganism that cause disease.

Space and PrivacySpace and Privacy

Purpose of Space

1. Importance of space

2. Nurse's role in protecting client space

Maintaining the client's right to privacy

1. Screening

2. Requesting family/ friends to leave the room

3. Draping

4. Client consent to view procedures

Environmental factors related to comfort & safety

Temperature of room

Relative humidity

Physical hazards

Carcinogens

Pathogens

Pollution

Developmental factors

Effects of Sensory Deprivation

Cognitive Decreased learning Bizarre thinking

Affective Boredom Restlessness Increased anxiety

Perceptual Decreased attention span Confusion

Personnel Maintaining Client Environment

Medical and Nursing staff

Housekeeping

Engineering /Maintenance/Maintenance

Common Hospital Injuries/Safety

Common Hospital InjuryCommon Hospital Injury

Falls

Client-Incurred Accidents

Procedure-Related Accidents

Equipment-Related Accidents

SafetySafety

Fire Safety

Earthquake Safety

Disaster Preparedness

Preventing FallPreventing Fall

Identifying at-risk patientsIdentifying at-risk patients Assess for a history of fallsAssess for a history of falls Assess for additional risk factorsAssess for additional risk factors

Combining an assessment tool with a care planCombining an assessment tool with a care plan

Accurate assessment and use of appropriate fall Accurate assessment and use of appropriate fall interventionintervention

Preventing Falls: Preventing Falls:

Determine the client's diagnoses and capabilities

Floors Clean and DryFloors Clean and Dry

Floor Free from Clutter Floor Free from Clutter

Anticipate Client Needs (toileting etc.)Anticipate Client Needs (toileting etc.)

Know ClientKnow Client’’ Diagnosis (eg.) CVA Blind Diagnosis (eg.) CVA Blind ClientClient’’s, Alzheimer's s, Alzheimer's

Keep Belongings and Call Light in Reach, Bed Keep Belongings and Call Light in Reach, Bed in Low Position and Locked, Side Rails (!!!) in Low Position and Locked, Side Rails (!!!)

Breaking ClientBreaking Client’’s Fall:s Fall:

Stand with your feet apart slightly behind the Stand with your feet apart slightly behind the clientclient

Grasp the client firmly at waist/axillaGrasp the client firmly at waist/axilla

Your near leg against the clientYour near leg against the client’’s legs leg

Slowly lower the client to the floorSlowly lower the client to the floor

Examine for injuryExamine for injury

Call for helpCall for help

Document as per agency policyDocument as per agency policy

Doctor notifiedDoctor notified

Interventions for a Patient Interventions for a Patient Who Experiences a FallWho Experiences a Fall

Immediately assess the patientImmediately assess the patient’’s conditions condition

Provide care and interventions appropriate for Provide care and interventions appropriate for status/injuriesstatus/injuries

Notify patientNotify patient’’s physician or primary caregiver of s physician or primary caregiver of incident and your assessment of the patientincident and your assessment of the patient

Ensure prompt follow-through for any test ordersEnsure prompt follow-through for any test orders

Evaluate circumstances of the fall and the Evaluate circumstances of the fall and the environment; institute preventive measuresenvironment; institute preventive measures

Document the fall and complete an event reportDocument the fall and complete an event report

Alternatives to Restraints Alternatives to Restraints

Determine whether a behavior pattern existsDetermine whether a behavior pattern exists

Assess for pain and treat appropriatelyAssess for pain and treat appropriately

Rule out physical causes for agitationRule out physical causes for agitation

Involve family membersInvolve family members

Reduce stimulation, noise, and lightReduce stimulation, noise, and light

Check environment for hazards and modify, if necessaryCheck environment for hazards and modify, if necessary

Use therapeutic touchUse therapeutic touch

Investigate discontinuing bothersome treatment devicesInvestigate discontinuing bothersome treatment devices

Restraints:Restraints:PurposePurpose

Applied for safetyApplied for safetyPrevent injuryPrevent injuryPrevent dislodgement Prevent dislodgement

of tubesof tubesPsychiatric SettingPsychiatric Setting

RestraintsRestraintsLegal Consideration:Legal Consideration:

Must be ordered by a physician in writingMust be ordered by a physician in writing

Emergency (can be applied by a nurse, orders Emergency (can be applied by a nurse, orders within 24-48 hours)within 24-48 hours)

Documentation (all that was done to remedy Documentation (all that was done to remedy situation before applying)situation before applying)

Restraints:Restraints:Must !!!Must !!!

Must help client or be needed for medical Must help client or be needed for medical therapytherapy

Must be ordered by a physicianMust be ordered by a physician

Must not be used as a means of pushing or Must not be used as a means of pushing or disciplining the clientdisciplining the client

Must be applied snugly/not tightlyMust be applied snugly/not tightly

Must be removed/Reposition Q2 Must be removed/Reposition Q2

Must notify doctor when no longer neededMust notify doctor when no longer needed

Must intervene to promote safetyMust intervene to promote safety

Must be documented Must be documented

RestraintsRestraintsTypes:Types:

Safety BeltsSafety BeltsWrist Extremity ImmobilizerWrist Extremity ImmobilizerVest (Posey)Vest (Posey)Hand MittensHand MittensLeatherLeatherChemicalChemical

RestraintsRestraintsBasic Principals: Basic Principals:

Know agency policyKnow agency policy

Document use of restraints and patient Document use of restraints and patient monitoringmonitoring

Check client Q 15 minutesCheck client Q 15 minutes

Remove and reposition Q 2 hoursRemove and reposition Q 2 hours

Assist with ROMAssist with ROM

Call light in reachCall light in reach

Comfort measure (eg) water, food, rest Comfort measure (eg) water, food, rest roomroom

RestraintsRestraintsBasic Principals: Basic Principals:

FamilyFamily

Diversional ActivitiesDiversional Activities

Psycho/Social (tough, isolation, confusion)Psycho/Social (tough, isolation, confusion)

ClientClient’’s daily habits (eg) news papers daily habits (eg) news paper

Neuro/Vascular AssessmentNeuro/Vascular Assessment

Rapid Release of RestraintsRapid Release of Restraints

R-E-S-T-R-A-I-N-T AcronymR-E-S-T-R-A-I-N-T Acronym

RR: Respond to the present, not the past: Respond to the present, not the past

EE: Evaluate the potential for injury: Evaluate the potential for injury

SS: Speak with family members or caregivers: Speak with family members or caregivers

TT: Try alternative measures first: Try alternative measures first

RR: Reassess the patient to determine success of : Reassess the patient to determine success of

restraintrestraint

AA: Alert the physician and family of need for restraint: Alert the physician and family of need for restraint

II: Individualize restraint use: Individualize restraint use

NN: Note important information on chart: Note important information on chart

TT: Time limit the use of restraints: Time limit the use of restraints

RestraintsRestraintsLong Term Use Long Term Use

(problems):(problems): Muscle weakness, atrophyMuscle weakness, atrophy

Loss of bone mass, joint contracturesLoss of bone mass, joint contractures

Constipation/incontinenceConstipation/incontinence

Pressure UlcersPressure Ulcers

Cognitive ImpairmentCognitive Impairment

Decrease confidence in ambulationDecrease confidence in ambulation

Withdrawn, detachedWithdrawn, detached

DepressionDepression

Loss of independenceLoss of independence

ConclusionConclusionAsk Yourself:Ask Yourself:

Is my client safe from harm?Is my client safe from harm?

Does my client need anything?Does my client need anything?

Is the bed locked?Is the bed locked?

Is the bed in the low position?Is the bed in the low position?

Is the call light in reach?Is the call light in reach?

Does my client have anything to do?Does my client have anything to do?

How is my clientHow is my client’’s neuro/vascular s neuro/vascular assessment?assessment?

Physical RestraintsPhysical Restraints

Restrict or control movement or behavior. Restrict or control movement or behavior. They may be attached to a person's body They may be attached to a person's body or create physical barriers.or create physical barriers.

wristwrist

vestvest

side railsside rails

wheelchair safetywheelchair safety

hand mittens hand mittens

Securing Restraint to Bed Securing Restraint to Bed FrameFrame

Restraint Secured Behind Restraint Secured Behind ChairChair

Using a Hand MittUsing a Hand Mitt

Child With Elbow Restraint in Child With Elbow Restraint in PlacePlace

Chemical Restraints Chemical Restraints

Chemical Restraints - Chemical Restraints - are any medication are any medication used for the purpose of restraining patients used for the purpose of restraining patients involuntarily to prevent them from harming involuntarily to prevent them from harming themselves or staff. themselves or staff.

Advantages of chemical restraintsAdvantages of chemical restraints

Control violent behavior and patient Control violent behavior and patient agitation agitation

May reduce need for physical restraints May reduce need for physical restraints

Allow examination and performance of Allow examination and performance of radiographic imaging radiographic imaging

Disadvantages of Chemical Disadvantages of Chemical RestraintsRestraints

• May result in complications, such as May result in complications, such as respiratory depression and loss of gag respiratory depression and loss of gag reflex reflex

• Occasional paradoxical reaction results Occasional paradoxical reaction results in increased agitation in increased agitation

• Limit mental status assessment and Limit mental status assessment and neurologic examination during neurologic examination during sedation sedation

Environmental RestraintsEnvironmental Restraints

Change or modify a person's surroundings to Change or modify a person's surroundings to restrict or control movement. For example, a restrict or control movement. For example, a locked door.locked door.